Should Men Get PSA Tests to Screen for Prostate Cancer?

By

Melinda Beck

Updated Feb. 14, 2013 9:41 pm ET

One in six American men will be diagnosed with prostate cancer in their lifetimes. In most cases, the disease grows so slowly it doesn't cause problems. Yet some prostate cancers are fast-moving and lethal; about 28,000 U.S. men die every year because it wasn't detected and treated in time.

A test for prostate-specific antigen, or PSA, a protein made in the prostate, can give an early warning sign of cancer. But PSA tests also give many false alarms, prompting more than one million unnecessary biopsies every year. And when prostate cancer is found, more than 80% of men opt for surgery, radiation or hormone therapy that sometimes leaves them incontinent or impotent, even though their cancer probably wasn't life-threatening.

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The U.S. Preventive Services Task Force, a nongovernmental panel of independent experts in prevention and evidence-based medicine, recently recommended doctors stop using PSA tests to screen men with no symptoms of prostate cancer. That prompted an outcry from some experts and advocacy groups concerned that prostate cancer would be missed, and many doctors have continued to order the tests.

Richard Ablin, a professor of pathology at University of Arizona College of Medicine, discovered the prostate-specific antigen in 1970, and for nearly as long, he has argued that it should not be used for routine screening. Oliver Sartor, medical director of Tulane Cancer Center in New Orleans, counters that while it isn't perfect, PSA testing has saved lives.

Here are edited excerpts from their debate.

WSJ: Why not use PSA tests for routine screening, Dr. Ablin?

RICHARD ABLIN: 'There's no PSA level that definitely indicates that prostate cancer is present.'
University of Arizona

DR. ABLIN: PSA is not cancer-specific; a rising PSA level can be due to an infection or benign prostate enlargement as well as cancer. There's no PSA level that definitely indicates that prostate cancer is present. And prostate cancer is an age-related disease. Between 40% and 80% of men aged 50 to 75 possess asymptomatic cancer, so cancer may well be found. However, the PSA test can't distinguish an indolent cancer from an aggressive one.

DR. SARTOR: I get my own PSA regularly tested because there is no better test for the early detection of prostate cancer and some of these cancers are life-threatening. Is PSA perfect? Not by any means. Is PSA the best we have today? Yes.

Those against PSA tests are people who do not take care of prostate-cancer patients. Physicians who do are almost all in favor of PSA testing, and the vast majority of them get PSA testing themselves (gender and age appropriate, of course).

WSJ: Has it saved lives or not? Isn't it easier to treat prostate cancers detected early?

OLIVER SARTOR: 'We can stratify patients into low, intermediate and high risk categories.'
Tulane University

DR. SARTOR: Since PSA screening became routine in the 1990s, prostate-cancer mortality rates have declined by nearly 40%. I think PSA testing is the most likely explanation.

A recent article in the journal Cancer estimated that without PSA testing, the number of men initially diagnosed with metastatic (incurable) cancer would be nearly three times higher. That's an additional 17,000 men annually. We know that not all these men would be cured if detected earlier, but PSA testing dramatically improves the odds that prostate cancer will be found before it becomes incurable.

DR. ABLIN: The Cancer article relies on calculations, approximations and speculation with one assumption built on another. There is no clinical data to support these assumptions.

Remember, "First do no harm." PSA screening has serendipitously saved some lives, but at a huge toll given the estimated one million men who have been treated unnecessarily since the FDA approved the use of the PSA test for diagnosis in 1994, many of whom suffered infections or other complications, including incontinence and impotence.

In all likelihood, other factors contributed to the decrease in prostate cancer deaths, including better treatments and surgical techniques, healthier patients with longer life expectancies and increased awareness so more men with symptoms saw their doctors and were referred to a urologist. We are also getting more precise at determining causes of death, and there has been a decrease in mortality across the board in most cancers.

WSJ: Is the PSA test the real problem or how the results are interpreted and acted on?

DR. SARTOR: PSA is not the real issue. The main problem is that too many men are unnecessarily treated for cancers that will ultimately prove to be of little harm.

But we can readily determine which prostate cancers need treatment and which do not. By combining the Gleason score (determined by a pathologist examining cancer cells under a microscope), the clinical stage (determined by a careful prostate exam and various scans) and the PSA level, we can stratify patients into "low," "intermediate" and "high" risk categories.

This is done in all major cancer centers. It's clear to me that most men with a low risk of prostate cancer would benefit from surveillance instead of immediate treatment.

I make a distinction between surveillance and "watchful waiting," as do many in the field. Surveillance means following the patient over time and offering treatment if warranted.

DR. ABLIN: If we really could determine which cancers need treatment and which don't, we wouldn't be having this debate. Furthermore, no absolute level of PSA will work. Some patients have a PSA of 0.5 and have cancer and some have a PSA of 11 and do not. And two patients with a similar Gleason score and clinical history may have very different outcomes.

WSJ: Do PSA tests make sense only in men at high risk? What would you do about the others?

DR. ABLIN: Men who have a family history of prostate cancer—that is, a father, brother or uncle who had it—should get an annual test, starting at age 40 to serve as a base line.

Patients diagnosed with prostate cancer who choose "active surveillance" over immediate treatment can follow changes in their PSA over time to help with decision making. And for patients already treated for prostate cancer, an increase in PSA may serve as a "harbinger" for the recurrence of disease.

Men with symptoms such as pain in the lower back or groin area, pain on urination, frequent urination or blood in the urine, should get their PSA tested to check for diseases such as prostatitis, benign prostate hyperplasia and/or prostate cancer.

But for other men, the ability of the PSA test to detect prostate cancer is slightly better than the flip of a coin.

DR. SARTOR: All men over 50 with a 10-year life expectancy should have their PSA tested annually. African-American men and men with a family history of prostate cancer should be especially vigilant.

But if men are diagnosed with prostate cancer, before deciding that treatment is necessary, they should seek advice from a prostate-cancer expert who is comfortable with doing active surveillance. Not all prostate cancer should be treated.

The Readers Weigh In: PSA Testing

Should men get PSA tests to screen for prostate cancer? Here's what some WSJ.com readers had to say in an advance poll.

Knowing gives options, even the option of doing nothing, that ignorance does not provide.

Robert Levit

I can honestly say after losing three brothers to cancer, I agree that the PSA test saved my life. I vote yes to the test!

Kenneth Locklear

I had a PSA reading that was considered high for my age. After the biopsy, which was negative, my PSA scores came down. So I was one of the over 1 million unneccessary biopsies. It was a big waste of time and money. The actual biopsy was one of the worst, most painful experiences in my life. Even if I died of prostate cancer at a very old age it would have been better than all worrying and angst.

David D. Wong

I had higher than normal reading, 5.5. Took antibiotics and it went down to 3.9. Doc still wanted biopsy (which was negative) but procedure gave me sepsis! Five days in the hospital and now I am dealing with "performance" issues that weren't there before! Weigh your options carefully!

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